Transforming Outcomes for Patients Through Medical Home Evaluation & reDesign

Health Information Technology Clinical Trial

— TOPMED  

Official title:

Transforming Outcomes for Patients Through Medical Home Evaluation & reDesign

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT02106221
• Other study ID #: GBMF2908
• Status: Completed
• Phase: Phase 3
• First received: March 21, 2014
• Last updated: July 28, 2015
• Start date: July 2011
• Est. completion date: February 2015

Study information

• Verified date: July 2015
• Source: Care Management Plus
• Contact: n/a
• Is FDA regulated: No
• Health authority: United States: Institutional Review Board
• Study type: Interventional

Clinical Trial Summary

The purpose of this study is to support enhancement, implementation, and evaluation of an improved model for delivering improved primary care to high-risk older adults through the use of health IT tools, focusing on issues related to the patient-centered primary care home (PCPCH) and other similar high-value elements that are proposed to improve patient outcomes. During this study, participating clinics will utilize the already-implemented Integrated Care Coordination Information System (ICCIS). Clinic staff will meet with a practice facilitator (monthly and as needed), and will track study activities and submit invoices via ICCIS reporting. These invoices will be used to simulate a shared savings model where clinics will be reimbursed based on their progress and effort towards their goals.

Clinics will set and work towards goals that they have chosen. Goals for the control arm are self-selected by the clinics themselves; goals for the invention arm are related to high-value elements (HVE) that have been identified as areas that can improve patient outcomes. These HVE are:

1. Evidence-based Care Management Based on Need

2. Identification of At-Risk Populations

3. Patient Engagement and Alerts Based on Goals

4. Integrated Information for Care Management, especially around Utilization

5. Population Management Tools

Recruitment information / eligibility

• Status: Completed
• Enrollment: 65500
• Est. completion date: February 2015
• Est. primary completion date: June 2014
• Accepts healthy volunteers: No
• Gender: Both
• Age group: 18 Years and older

Eligibility

Inclusion Criteria:

• clinics must be from the Oregon Rural Practice-based Research Network (ORPRN)

• Primary care clinic meeting one of the following health care setting descriptions: 1) small clinics in rural area, 2) medium-sized clinics in rural area, 3) clinics in moderate-sized health system, or 4) clinic within an academic medical center;

• Clinic will or has attested for PCPCH, achieving Tier 2 or 3 (of 3 tiers);

• Clinic is willing to contract to be a PCPCH with payers;

• Clinic has stable electronic health record (EHR) system with no plans to change systems during study duration;

• Clinic has willingness to receive practice facilitation and participate in study activities, including completion of assessments;

• Clinic has willingness to engage with research team members as defined in the study.

Exclusion Criteria:

• patients less then 18

Study Design

Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Single Blind (Subject), Primary Purpose: Supportive Care

Related Conditions & MeSH terms

• Health Information Technology
• Nurse Based Care Management

Intervention

Other:
• Intervention
Will receive payments based on achievement in meeting goals based on specified high value elements as well as effort.
• Control
Will receive payments based on achievement in meeting goals.

Locations

Country	Name	City	State
United States	Oregon Health & Science University	Portland	Oregon

Sponsors (2)

Lead Sponsor	Collaborator
Care Management Plus	Gordon and Betty Moore Foundation

Country where clinical trial is conducted

United States, 

References & Publications (1)

Dorr DA, McConnell KJ, Williams MP, Gray KA, Wagner J, Fagnan LJ, Malcolm E. Study protocol: transforming outcomes for patients through medical home evaluation and redesign: a cluster randomized controlled trial to test high value elements for patient-centered medical homes versus quality improvement. Implement Sci. 2015 Jan 22;10:13. doi: 10.1186/s13012-015-0204-6. — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Preventable utilization	Reduce by 15% ED visits and hospitalizations related to ambulatory care	12 months	No
Primary	Quality Measures Improvement	Select 3 standard measures related to the patient population and improve each by 20%. (An example of such a measure might be fall risk assessment. There are several quality measures that are included as part of the HIT tool that is provided to clinics.)	12 months	Yes
Primary	Patient Satisfaction	Improve patient experience with clinic and satisfaction with care coordination by 10% Patient satisfaction will be determined by a CAHPS patient satisfaction survey that is sent out at the start and end of the study.	12 months	No

External Links

•   Trial website